Shoulder dislocation

Shoulder dislocation by Dr Bipul Borthakur

1. SHOULDER DISLOCATION Dr. Bipul Borthakur Professor, Dept. of Orthopaedics, SMCH

2. Anatomy of shoulder joint Glenohumeral joint – ball and socket type of synovial joint Most mobile joint in the body, but compromised in its stability Glenoid cavity: shallow; anteverted and inferiorly angulated from the long axis of the scapula

3. ANATOMY OF SHOULDER JOINT

4. Anatomy of shoulder joint Labrum : fibrocartilage attached to the edge of the glenoid . Capsule and ligaments: fibrous capsule, weak point in the inferior part . Rotator cuff: subscapularis , supraspinatus, infraspinatus and teres minor Bursae : sub-deltoid and sub-acromial

5. FACTORS RESPONSIBLE FOR STABILITY OF SHOULDER JOINT Capsulolabral complex Rotator cuff Negative intra-articular pressure Synovial fluid adhesion-cohesion

6. MINUS FACTORS Increased range of movements of shoulder joint

7. Shoulder dislocation Factors responsible for shoulder dislocation: The shallowness of the glenoid socket Extraordinary range of movement Underlying conditions like ligamentous laxity, glenoid dysplasia Vulnerability of the joint during stressful activities of the upper limb

8. Classification

9. Anterior shoulder dislocation Represent 96% of shoulder dislocation Mechanism of injury Indirect injury: fall on outstretched hand with shoulder in Abduction, ER and extension. Direct injury: anteriorly directed force to the posterior shoulder

10. Anterior shoulder dislocation Clinical presentation Severe pain, inability to move the upper limb Limb will be held in abduction and external rotation On examination Loss of normal contour of shoulder – flattening / squaring of the shoulder Prominent acromion process Palpable globular mass anteriorly DNVD - Regiment badge sign due to axillary nerve injury

11. Anterior shoulder dislocation Special tests: Vertical circumference of the axilla – increased Hamilton ruler test Dugas ’ test-touch opp shoulder with arm on chest

12. Anterior shoulder dislocation Pathological lesions around glenohumeral joint Bankart’s lesion – avulsion of the labrum off the glenoid rim +/- glenoid rim fracture (Bony bankart lesion) Hill – Sach’s lesion – posterolateral defect caused by glenoid impression on the humeral head Erosion of glenoid rim Cause of recurrent dislocation

13. Anterior shoulder dislocation Investigaions : X-ray A nteroposterior and axillary views - to confirm the diagnosis CT scan – to diagnose bony lesions MRI – to diagnose ligamentous laxity and soft tissue injuries Arthrography – to evaluate rotator cuff tears

14. AP View

15. ANTERIOR DISLOCATION

16. Anterior shoulder dislocation Treatment: Closed or open reduction Closed reduction techniques: under general anesthesia Hippocratic technique Stimson gravity technique Kocher’s maneuver / Traction countertraction technique Milch technique Scapular manipulation Open reduction: Surgical reduction of dislocation First time dislocation in young active men Soft tissue interposition Displaced (>5mm) g reater tuberosity fracture and glenoid rim fracture >5mm in size

17. Stimson method

18. Milch method

19. Hippocratic method

20. Kocher method

21. Anterior shoulder dislocation Post-reduction protocol: Repeat X-ray to confirm the reduction Immobilize the shoulder using Universal shoulder immobilizer for 3weeks Physiotherapy after 3 weeks Complications: Early: Fractures around the joint – Humeral head, GT, glenoid rim, acromion and coracoid Soft tissue injuries – Rotator cuff tears, capsular tears Neurovascular injuries – axillary artery and nerve, musculocutaneous nerve; usually occurs in adults Late: Recurrent dislocation, unreduced dislocation Shoulder stiffness due to post-traumatic arthitis

22. Posterior shoulder dislocation Represent 2% - 4% of shoulder dislocation Mechanism of injury: Direct or Indirect trauma Electric shock or convulsive mechanisms Clinical presentation: Pain, restricted movements, arm held in internal rotation and adduction On examination: Palpable mass posterior to the shoulder Prominent coracoid process Flat shoulder contour, empty glenoid DNVD – Axillary nerve

23. Posterior shoulder dislocation Investigations: X-ray shoulder anteroposterior and axillary view CT scan – to evaluate any associated fractures Treatment: Closed or open reduction Complications: Early: Fractures around the shoulder joint Neurovascular injury Late: Unreduced or recurrent dislocation Anterior dislocation – usually results due to overtightening the posterior structures Light bulb appearance

24. Complications: Early: Fractures around the shoulder joint Neurovascular injury Late: Unreduced or recurrent dislocation Anterior dislocation – usually results due to overtightening the posterior structures

25. Inferior shoulder dislocation Occurs rarely, usually in elderly individuals Also known as Luxatio erecta Mechanism of injury: Severe hyperabduction force Clinical presentation Severe pain Upper limb held in hyperabduction On examination Humeral head is palpable on the lateral chest wall or the axilla DNVD – injury to brachial plexus and axillary artery are common

26. Inferior shoulder dislocation Investigations: X-ray AP view – diagnostic; look for associated fractures around the shoulder joint MRI – soft tissue injuries Treatment : Closed or open reduction Complications: Rotator cuff avulsions and tear, pectoralis injury Proximal humeral fractures Neurovascular injury – axillary artery and brachial plexus; usually recovers after the reduction

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